Healthcare Provider Details

I. General information

NPI: 1174997647
Provider Name (Legal Business Name): KAITLIN DIVINNIE AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE BLDG B
ATLANTA GA
30322-3736
US

IV. Provider business mailing address

3518 PRESERVE DR SE
ATLANTA GA
30339-3736
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3184
  • Fax:
Mailing address:
  • Phone: 615-973-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN224677
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN224677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: